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        <p>2019上海展会上的课程，我没去现场，听的网络直播。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/01.png"><br>兖州口腔医院的高洪德老师讲的。<br>盗了人家的图，把直播赞助商也放上来吧。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/02.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/03.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/04.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/05.png"><br>如何拔阻生牙有技巧。常常很简单的阻生牙，有的医生分牙后难度往往增加了(我经常干这样的事，嘿嘿）。如何精准化分割阻生牙？操作技巧。<br>无痛化-舒适化-精准化-程序化-简单化。<br>一、一般阻生状态<br>高位、中位、低位<br>软组织覆盖<br>倒置阻生<br>横位（颊舌向）<br>二、阻力分析及麻醉<br>下8拔除难度分析（老师自创的吧？）<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/06.png"><br>15分以下容易拔除<br>16-20分难度较大<br>21分以上困难（包含所有骨埋伏智齿、多生牙、乳牙的埋伏阻生）<br>结合自己的操作技能，以及阻生牙的数字量化的分数来判断你所接诊的患者。<br>麻醉<br>改良式下牙槽N注射法<br>要点：对侧进针，升支前缘后2cm，平齐咬合面进针点。5%-24%的人有颈横神经在下颌骨舌侧进入下颌骨参与下颌神经的管理(嘴唇麻了，拔牙还痛的原因）。<br>是患者的恐惧而不是麻药影响患者的血压。<br>在8的远中有时有下颌神经的副神经。要在8的远中和颊侧浸润麻醉。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/07.png"><br>注射点过高，变异比较大。可能效果不好。注射点平齐下颌牙合平面就行，刚好在下颌神经孔的位置。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/08.png"><br>一进针就碰到骨壁的处理：调整到同侧，沿下颌升支骨壁滑行，滑行2cm左右再转至对侧，注射。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/09.png"><br>三、方案设计<br>1.角型切割<br>(1)近中角型切割<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/10.png"><br>适用于近中水平中位以上阻生的牙齿<br>A.7远中外形高点<br>O.8远中与骨质的接触点<br>B.8牙冠的低点<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/11.png"><br>连接OA，OB<br>OA脱位空间<br>OB转动半径<br>OB&gt;OA，没法脱位。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/12.png"><br>截冠（角度30°-60°，低了，OB增加不多，还是无法脱位，高了，远中不能成立，增加手术难度）<br>OB’&lt;OA<br>去骨<br>O’B’&lt;O’A<br>(教怎么分冠，课程的精华了。）<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/13.png"><br>病例，从颊侧，提拉式切割。保留舌侧20%左右（保护舌侧牙槽骨及牙龈）。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/14.png"><br>在牙冠上形成1mm左右的间隙。超声骨刀在远中增隙1mm左右。选用3-3.5mm宽的牙挺，（1mm宽）牙挺放到切割的最底部，右侧患牙顺时针旋转牙挺，牙冠从舌侧和远中上抬。远中冠和牙根就一起出来了。再取出近中冠。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/15.png"><br>这样的牙最危险的是冠拿出来了，去掏根，结果跑到咽旁间隙了。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/16.png"><br>(2)远中切割<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/17.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/18.png"><br>远中和颊侧有骨质覆盖的。<br>解除骨阻力，然后把牙从近中往远中推。<br>(3)纵行分离<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/19.png"><br>阻力在外形高点处。<br>冠纵分，远中松解。<br>2.横断式<br>适应症：埋伏牙、完整取出会破坏大量骨质<br>(1)冠根分离<br>一般在外形高点以下，釉牙骨质界以上。<br>(2)T型切割<br>还取不出来，再纵分冠<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/20.png"><br>(3)十字型切割<br>取根取不出来，再分根。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/21.png"><br>临床上常用牙挺在根分叉那里撬就分开了。<br>3.隧道式<br>多用于前牙埋伏阻生的。拔的时候小心别把恒牙弄出来。这种我就转诊了。pass。<br>四、操作技巧<br>近中切割<br>注意切割深度<br>远中松解<br>25mm长的车针，放到快机上以后长度只剩约15mm，切割从颊侧开始，一直打到牙槽骨，到了以后以这个点为基准上下提拉。注意保留舌侧20%。拔右侧牙齿时往顺时针转挺，使牙根往远中舌侧移动，否则往颊侧挺会向下颌升支运动，阻力较大。左侧逆时针转挺。同理，右侧上颌阻生牙，顺时针（腭侧骨壁较厚）。<br>去阻<br>正确分割牙冠：去除阻力冠<br>角型分割：二类中位近中水平以上的智齿。<br>远中分割：三类远中阻生或远中有骨覆盖。<br>纵分切割：低位埋伏双根骨质覆盖外形高点线以上。<br>横断式：适合埋伏牙<br>冠根分离-T型切割-十字型切割。<br>牙冠不按我们设计的方案分离怎么办？<br>由于不同的切割角度以及远中骨质覆盖的阻力不同，会产生不同的牙冠分离现象。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/22.png"><br>两种不同的切割线的切割效果对比。<br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/23.png"><br><img src="https://zymblog-1258069789.cos.ap-chengdu.myqcloud.com/blog0156-zszcjzqg/24.png"><br>切割深度不够，把露出的牙冠磨了，牙根没动，近中冠没有分离，把简单的事复杂化了。磨得太宽了，牙冠挺不开了，丧失支点。（我就爱犯这样的错误。）<br>近中切割是关键：去冠接触邻牙阻力。<br>远中松解是法宝：增隙为牙齿上抬脱位创造空间。<br>牙根已经送了才断根不可怕，怕的是牙根没松牙冠断了。<br>接下来是老师的案例，就略了。<br><strong>听课总结：关键还是要在动手以前想清楚要怎么解除阻力，设计好再动手，而不是匆忙开始踩机器磨牙齿，出了问题再想办法来解决。解决问题永远比不上避免问题。谢谢高老师！</strong></p>
<p>我发文章的三个地方，欢迎大家在朋友圈等地方分享，欢迎点“在看”。<br>我的个人博客地址：<a href="https://zwdnet.github.io/">https://zwdnet.github.io</a><br>我的CSDN博客地址：<a target="_blank" rel="noopener" href="https://blog.csdn.net/zwdnet">https://blog.csdn.net/zwdnet</a><br>我的微信个人订阅号：赵瑜敏的口腔医学学习园地</p>
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